By: Nitu Joseph
Many a time, mindlessly some of us happen to throw the expired medicines or the ones deemed useless into that old little dustbin at the corner of the house. For most of us, our commitment to the cause of waste disposal ends there, or so we think. Little is known of what happens to these medicines thrown into the trash cans later. At first glance, there seem to be no clear connections between humanity’s pressing problems: environmental waste and antimicrobial resistance (AMR). In fact, there is an inevitable convergence across these medical and environmental domains that hinge on social and economic inequalities.
Antibiotics are medicines used to prevent and treat bacterial infections. These are different from almost every other class of drug in one important and dangerous respect: the more they are used, the less effective they become. Its resistance occurs when bacterial strains undergo minor genetic mutations in response to the use of these medicines. Bacteria, not humans or animals, become antibiotic-resistant. Superbugs or antibiotic-resistant bacteria are the organisms that have acquired resistance to antibiotics when exposed to mild doses of the same for a prolonged period of time. These bacteria may infect humans and animals, and the infections they cause are harder to treat than those caused by non-resistant bacteria. India is staring down the barrel of such a ‘superbug outbreak’.
Antibiotics are entering in large quantities into the environment. According to one study, the primary pathway of antibiotics into the environment is the use and disposal of out-of-date or unwanted medicines whose eco-toxicologic consequences are yet to be clear. The complex pathways of the interaction of these outdated drugs with the waste management chain are given little attention. As per a study in Patancheru, which is a major production site of the generic drugs for the world market near Hyderabad in India, high levels of several broad-spectrum antibiotics, specifically ciprofloxacin, are present in aquatic environment. A degree of multiple antibiotic resistance was observed in seven different Vibro species in the coastal water of Bay of Bengal at Orissa coast.
Each year, an estimated 750,000 people die from antimicrobial-resistant (AMR) infections, and the death toll will climb unless the problem is tackled holistically. Methicillin-Resistant Staphylococcus Aureus (MRSA) is one of the most well-known and deadliest types of drug-resistant bacteria. It has become a lightning rod for debates about how to reign in MROs. Yet, it was the discovery of the ‘foreign’ origin of superbugs that brought the issue into the global limelight, and India was at the centre of it.
In India, a new multi-resistant strain was discovered in late 2008 in a Swedish traveller infected with common bacteria (Klebsiella pneumonia) but revealed to be carrying a drug-resistant gene that could be passed between bacteria across a range of species. It was soon named the New Delhi Metallo-beta-lactamase-1 (NDM-1). Then reports emerged in India of infants dying from bacterial infections that could not be treated by even the last resort (and often highly toxic) antibiotics. Deaths resulting from MROs are hard to pin down, and data on health-related illnesses and disease are often unreliable.
On average, research and development of a single new anti-microbial takes 10-20 years and costs $ 500 million US dollars to bring into the market. The rise of antibiotic-resistant bacteria is a major public health crisis as infections from resistant bacteria are becoming increasingly difficult and expensive to treat. When bacteria become resistant to first-line antibiotics, treatment has to be switched to second or third line drugs, which are generally expensive. Many of second and third line therapies for drug-resistant infections are unaffordable due to their high price. Over the last decade, almost, every type of bacteria has become resistant and less responsive to antibiotic treatment when it is really needed.
WHO in its 68th World Health Assembly, held in May 2015, endorsed a global action plan for tackling antimicrobial resistance. In the Indian context, in 2012, India’s medical societies adopted the Chennai Declaration, a set of national recommendations to promote antibiotic stewardship. In April 2017, Ministry of Health and Family Welfare had unveiled a comprehensive and multi-sectoral National Action Plan to combat antimicrobial resistance. Yet the major problem persists due to the limited availability of data.
Hospital environments have been extensively studied while there have been limited studies available in other environments. Risks posed by handling expired medicines and consequent AMR related disease burden on the waste picker community is a topic that is yet to be studied exhaustively to understand the far-reaching ramifications of the garbage problem.
Programs like the Redline initiative and Community Drug Take-Back scheme are yet to be effective in India. This calls for sensitization, widespread in this case, especially among the on-ground workforce that handles such waste on a daily basis, which is mostly left out of the routine campaigns. Communities need to rise above the social divide and have to strive towards facilitating the safe disposal of used medicines.
This multidisciplinary effort would call for active participation from a wide spectrum of the society ranging from waste pickers, health workers, researchers, engineers, teachers, doctors and policymakers to name a few. While the government ups its shield to battle any oncoming catastrophe, let’s hope it remains vigilant in this domain and strengthens the weakest links, for the battle against AMR is to be fought from level zero and the clock is already ticking.
About the Author:
Nitu is an Environmental engineer by profession and passion. Solo traveller. Backpacker. Explores waste management issues by working with multiple organizations dealing with grassroots level stakeholders.